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Plan Good Discharges

From: The Hospitalist, August 2008

Develop your arsenal of transition-of-care tactics

by Patrick J. Cawley, MD, FHM

Jeff Glasheen, MD

It was probably just the ramblings of a mad woman. Only she wasn’t mad, so I searched for a hint of delirium. Nothing. She was mentally fit and lucid—perhaps too lucid. Could it be true … had I become my archenemy?

To decide, I put her utterance to the test through the Kubler-Ross obstacle course, hopping the denial hurdle, quick-footing through the anger tire course, wading through the bargaining pool, and finally swinging safely across the depression crevasse to acceptance.

She was my eighth patient that day, a 78-year-old woman admitted to the orthopedic service with a hip fracture. I was asked to do a preoperative risk assessment and comanage her diabetes and heart failure. During our introductions she asked what kind of doctor I was.

Habitual tardiness, sketchy response times, vague payment structures, lack of transparency in pricing, pricing errors into the cost of the job—I don’t think the analogy was intended to be so perceptive. I and the healthcare system within which I work really had adopted some of the less-desirable attributes of the contracting world.

“A hospitalist,” I replied.

“Oh … that’s nice,” she answered, her furrowed eyebrow transforming her crow’s feet into a question mark.

“You know, a doctor who only cares for patients in the hospital,” I clarified. “I just take care of your acute problems.”

“You think a broken hip is cute?”

“No, no, not ‘cute.’ Acute. You know, I only deal with your urgent problems. When you leave here you will go back to see your primary care doctor, who will follow up your hip fracture and your more chronic issues.”

That’s when she dropped the bomb.

“Oh, I see; you’re sort of like a contractor for my body then—just helping when things get broke.”

I should explain my aversion to this comment. Reared by a 10-thumbed father, I’m genetically incapable of curing even the simplest household hiccup. This doesn’t mean I haven’t or won’t try. In fact, I’m willing to try anything. My wife, however, is too smart to allow that. She knows that home improvement project plus me equals larger home improvement project. Combine this mathematical axiom with our turn-of-the-(20th)-century home, and it’s easy to see why I find myself betrothed in nearly continuous engagement with contractors.

But this is a marriage on the rocks. As dependent as I am on home contractors, I generally dislike working with them. They’re all fine people I’m sure, and truth be told most of them are quite skilled at their work. The problem is that they go about their job as if they are allergic to customer service.

The only contractors who are not perpetually late are those who won’t give you a time to meet. “I’ll meet you in the morning,” they’ll say, only to define morning as any time after the sun comes up.

Then there’s the estimate, which appears to be an approximation calculated in a cavernous ballpark using an underestimater. It’s also not exactly clear how or what goes into the calculation of an estimate.

I recently got a written estimate that read as follows: “Fix sink, $400.” When I asked what the $400 would go toward, I got the ever-so-helpful reply: “Fixing the sink.” I responded, “No, I mean, how much are the parts and the labor and things like that?” He gruffly countered, “Four hundred dollars.” Uncovering how he came up with this estimate was about as easy as solving a Rubik’s cube. I gave up trying—and eventually paid $550.

Another time, a contractor agreed to fix a plumbing leak in our upstairs bathroom that had caused water damage to our first-floor ceiling. While tearing out the floor to reach the leak, he mistakenly ran a circular saw through a pipe, causing a considerably larger gusher that quickly destroyed said ceiling.

I understand these things happen. However, imagine my surprise when the eventual project cost was more than twice the estimated cost. He explained that repairing the new water damage was quite expensive and accounted for the variance with the estimate. We “discussed” this development, during which time I explained to him in no uncertain terms what the temperature in hell would be when I paid for his mistake.

So, it stung a bit to be called a “contractor.” But I could live with it. In fact, on the surface my patient’s analogy was quite good. Hospitalists do swoop in and fix patients’ problems only to then leave their lives, most often for good. It was only after a few days that her statement started to sour in my amygdala.

Habitual tardiness, sketchy response times, vague payment structures, lack of transparency in pricing, pricing errors into the cost of the job—I don’t think the analogy was intended to be so perceptive. I and the healthcare system within which I work really had adopted some of the less-desirable attributes of the contracting world.

I usually tell patients I’ll be back in an hour to give them their test results, knowing that I’m on “doctor time” and this could mean several hours or more. My tardiness usually results from being delayed while caring for another patient—but it’s all the same to the patient left waiting. Trying to build in cushion time for these unforeseen delays leaves a patient with a disagreeable contractor-like window of time to wait. For those who want to have their family at our daily rounds, an “I’ll come see you in the morning” is not just unhelpful—it disrespects the importance of their time.

Then there’s our payment system. It’s a mystery even to me: $12 aspirins, $100,000 cancer drugs, intentionally inflated professional fees and hospital bills that aren’t expected to be paid in full (unless the patient lacks an insurer to negotiate a lower price when they ironically are expected to foot the entire bill). All of which is made worse by the lack of transparency in our pricing. Patients (and most often I) simply are not privy to the costs of various tests and interventions. And, costs for the same procedure often differ among hospitals.

Few of us would contract for work without playing a role in choosing the supplies and knowing the rough cost of the materials. Yet that’s the situation our patients find themselves in daily.

Finally, expecting patients or their insurers to pay for my mistakes is not fair. I recognize there are adverse events that are unavoidable and should be reimbursed. However, many errors are as avoidable as being careful not to cut through a working pipe. Payment for these outcomes should be shouldered by the health system—not the patient.

I limped through the next few days re-examining my patient interactions. I licked my wounds, vowing to eschew those traits that so offend me as a consumer. I might not be able to repair a broken healthcare system, but I can refurbish the way I interact with my patients by being timely and responsive and not underestimating the effect of poor customer service. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado, Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.


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